Nursing Elites

1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

• A. Weak, nonproductive cough effort
• B. Large amounts of greenish sputum
• C. Respiratory rate of 28 breaths/minute
• D. Resting pulse oximetry (SpO2) of 85%

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

2. Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?

• A. Manage secretions by providing suction on a regular basis
• B. Cleanse the site daily with a mixture of povidone-iodine and water
• C. Avoid using tube ties to secure the tube
• D. None of the above

Correct answer: A

Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation. Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine. Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability. Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.

3. The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?

• A. Place the patient under contact precautions
• B. Use strict aseptic technique when caring for the wound
• C. Place another dressing to reinforce the first one
• D. Elevate the patient's leg to prevent more drainage

Correct answer: A

Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.

4. When caring for a patient hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of the patient. Which action, if performed by the student nurse, would require an intervention by the nurse?

• A. The patient is offered a tissue from the box at the bedside.
• B. A surgical face mask is applied before visiting the patient.
• C. A snack is brought to the patient from the unit refrigerator.
• D. Hand washing is performed before entering the patient's room.

Correct answer: B

Rationale: When caring for a patient with active tuberculosis (TB), it is crucial to use a high-efficiency particulate-absorbing (HEPA) mask instead of a standard surgical mask when entering the patient's room, as a HEPA mask can filter out 100% of small airborne particles, reducing the risk of transmission. Therefore, if the student nurse applies only a surgical face mask before visiting the patient, this action would require intervention by the nurse to ensure the appropriate protective equipment is used. Hand washing before entering the patient's room is essential to prevent the spread of infection and is a correct action. Bringing a snack to the patient from the unit refrigerator is appropriate and helps address potential issues with anorexia and weight loss in patients with TB. While hand washing after handling a tissue used by the patient is necessary, no special precautions are required when offering the patient an unused tissue.

5. The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. What action should the nurse take next?

• A. Auscultate anterior and posterior breath sounds bilaterally
• B. Encourage the patient to turn, cough, and deep breathe
• C. Review the chest x-ray report for evidence of pneumonia
• D. Palpate the anterior chest and observe for barrel chest

Correct answer: A

Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99'. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with conditions like pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Encouraging the patient to turn, cough, and deep breathe is an appropriate intervention for atelectasis, but assessing breath sounds takes priority. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). Palpating the anterior chest for fremitus is less effective due to the presence of large muscles and breast tissue, making auscultation a more appropriate next step.

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